Mnemonics in a Nutshell

Current PsychiatryVol. 7, No. 10 27

Mnemonics in a mnutshell:32 aids to psychiatric diagnosis

Clever, irreverent, or amusing, a mnemonic you rememberis a lifelong learning tool

Jason P. Caplan, MDAssistant clinical professor of psychiatryCreighton University School of MedicineOmaha, NEChief of psychiatrySt. Joseph’s Hospital and Medical CenterPhoenix, AZ

Theodore A. Stern, MDProfessor of psychiatryHarvard Medical SchoolChief, psychiatric consultation serviceMassachusetts General HospitalBoston, MA

From SIG: E CAPS to CAGE and WWHHHHIMPS,

mnemonics help practitioners and trainees recall

important lists (such as criteria for depression,

screening questions for alcoholism, or life-threatening

causes of delirium, respectively). Mnemonics’ effi cacy

rests on the principle that grouped information is easi-

er to remember than individual points of data.

Not everyone loves mnemonics, but recollecting

diagnostic criteria is useful in clinical practice and

research, on board examinations, and for insurance

reimbursement. Thus, tools that assist in recalling di-

agnostic criteria have a role in psychiatric practice and

teaching.

In this article, we present 32 mnemonics to help cli-

nicians diagnose:

• affective disorders (Box 1, page 28)1,2

• anxiety disorders (Box 2, page 29)3-6

• medication adverse effects (Box 3, page 29)7,8

• personality disorders (Box 4, page 30)9-11

• addiction disorders (Box 5, page 32)12,13

• causes of delirium (Box 6, page 32).14

We also discuss how mnemonics improve one’s

memory, based on the principles of learning theory.

How mnemonics workA mnemonic—from the Greek word “mnemonikos”

(“of memory”)—links new data with previously learned

information. Mnemonics assist in learning by reducing

the amount of information (“cognitive load”) that needs

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Current PsychiatryOctober 200828

Mnemonics

BOX 1. MNEMONICS FOR DIAGNOSING AFFECTIVE DISORDERS

DepressionSIG: E CAPS*Suicidal thoughts

Interests decreased

Guilt

Energy decreased

Concentration decreased

Appetite disturbance

(increased or decreased)

Psychomotor changes

(agitation or retardation)

Sleep disturbance

(increased or decreased)

* Created by Carey Gross, MD

DysthymiaHE’S 2 SAD2

Hopelessness

Energy loss or fatigue

Self-esteem is low

2 years minimum of depressed

mood most of the day, for more

days than not

Sleep is increased or decreased

Appetite is increased or decreased

Decision-making or concentration

is impaired

ManiaDIG FASTDistractibility

Indiscretion

Grandiosity

Flight of ideas

Activity increase

Sleep defi cit

Talkativeness

DepressionC GASP DIE1

Concentration decreased

Guilt

Appetite

Sleep disturbance

Psychomotor agitation or retardation

Death or suicide (thoughts or acts of)

Interests decreased

Energy decreased

HypomaniaTAD HIGH Talkative

Attention defi cit

Decreased need for sleep

High self-esteem/grandiosity

Ideas that race

Goal-directed activity increased

High-risk activity

ManiaDeTeR the HIGH*Distractibility

Talkativeness

Reckless behavior

Hyposomnia

Ideas that race

Grandiosity

Hypersexuality

* Created by Carey Gross, MD

to be stored for long-term processing and

retrieval.15

Memory, defi ned as the “persistence of

learning in a state that can be revealed at a

later time,”16 can be divided into 2 types:

• declarative (a conscious recollection of

facts, such as remembering a relative’s

birthday)

• procedural (skills-based learning, such

as riding a bicycle).

Declarative memory has a conscious

component and may be mediated by the

medial temporal lobe and cortical associa-

tion structures. Procedural memory has less

of a conscious component; it may involve

the basal ganglia, cerebellum, and a variety

of cortical sensory-perceptive regions.17

Declarative memory can be subdivided into

working memory and long-term memory.

With working memory, new items of infor-

mation are held briefl y so that encoding

and eventual storage can take place.

Working memory guides decision-

making and future planning and is intri-

cately related to attention.18-21 Functional

MRI and positron emission tomography

as well as neurocognitive testing have

shown that working memory tasks ac-

tivate the prefrontal cortex and brain

regions specifi c to language and visuo-

spatial memory.

The hippocampus is thought to rapidly

absorb new information, and this data is

consolidated and permanently stored via

the prefrontal cortex.22-26 Given the hippo-

campus’ limited storage capacity, new infor-

mation (such as what you ate for breakfast

3 weeks ago) will disappear if it is not re-

peated regularly.17

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Clinical Point

TKTK

Clinical Point

TKTK

BOX 2. MNEMONICS FOR DIAGNOSING ANXIETY DISORDERS

Long-term memory, on the other hand, is

encoded knowledge that is linked to facts

learned in the past; it is consolidated in

the brain and can be readily retrieved.

Neuroimaging studies have demonstrat-

ed opposing patterns of activation in the

hippocampus and prefrontal cortex, de-

pending on whether the memory being

recalled is:

• new (high hippocampal activity, low

prefrontal cortex activity)

• old (low hippocampal activity, high

prefrontal cortex activity).27

Mnemonics are thought to affect working

memory by reducing the introduced cog-

nitive load and increasing the effi ciency of

memory acquisition and encoding. They

reduce cognitive load by grouping ob-

jects into a single verbal or visual cue that

can be introduced into working memory.

Learning is optimized when the load on

BOX 3. MNEMONICS FOR DIAGNOSING MEDICATION ADVERSE EFFECTS

Antidepressant discontinuation syndromeFINISH7

Flu-like symptoms

Insomnia

Nausea

Imbalance

Sensory disturbances

Hyperarousal (anxiety/agitation)

Neuroleptic malignant syndromeFEVER8

Fever

Encephalopathy

Vital sign instability

Elevated WBC/CPK

Rigidity

WBC: white blood cell countCPK: creatine phosphokinase

Serotonin syndromeHARMEDHyperthermia

Autonomic instability

Rigidity

Myoclonus

Encephalopathy

Diaphoresis

Clinical Point

TKTK

Generalized anxiety disorderWorry WARTS3

Wound up

Worn-out

Absentminded

Restless

Touchy

Sleepless

Posttraumatic stress disorderTRAUMA5

Traumatic event

Re-experience

Avoidance

Unable to function

Month or more of symptoms

Arousal increased

Anxiety disorder due to a general medical conditionPhysical Diseases That Have

Commonly Appeared Anxious:

Pheochromocytoma

Diabetes mellitus

Temporal lobe epilepsy

Hyperthyroidism

Carcinoid

Alcohol withdrawal

Arrhythmias

Generalized anxiety disorderWATCHERS4

Worry

Anxiety

Tension in muscles

Concentration diffi culty

Hyperarousal (or irritability)

Energy loss

Restlessness

Sleep disturbance

Posttraumatic stress disorderDREAMS6

Disinterest in usual activities

Re-experience

Event preceding symptoms

Avoidance

M onth or more of symptoms

Sympathetic arousal

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Mnemonics

BOX 4. MNEMONICS FOR DIAGNOSING PERSONALITY DISORDERS

working memory is minimized, enabling

long-term memory to be facilitated.28

Mnemonics may use rhyme, music, or

visual cues to enhance memory. Most mne-

monics used in medical practice and edu-

cation are word-based, including:

• Acronyms—words, each letter of which

stands for a particular piece of information

to be recalled (such as RICE for treatment

of a sprained joint: rest, ice, compression,

elevation).

• Acrostics—sentences with the fi rst let-

ter of each word prompting the desired

recollection (such as “To Zanzibar by mo-

tor car” for the branches of the facial nerve:

temporal, zygomatic, buccal, mandibular,

cervical).

• Alphabetical sequences (such as ABCDE

of trauma assessment: airway, breathing,

circulation, disability, exposure).29

An appropriate teaching tool?Dozens of mnemonics addressing psychi-

atric diagnosis and treatment have been

published, but relatively few are widely

used. Psychiatric educators may resist

teaching with mnemonics, believing they

might erode a humanistic approach to pa-

tients by reducing psychopathology to “a

laundry list” of symptoms and the art of

psychiatric diagnosis to a “check-box” en-

deavor. Mnemonics that use humor may

be rejected as irreverent or unprofession-

al.30 Publishing a novel mnemonic may be

viewed with disdain by some as an “easy”

way of padding a curriculum vitae.

Entire Web sites exist to share mnemon-

ics for medical education (see Related Resources, page 33). Thus it is likely that

trainees are using them with or without

their teachers’ supervision. Psychiatric ed-

Paranoid personality disorderSUSPECT9

Spousal infi delity suspected

Unforgiving (bears grudges)

Suspicious

Perceives attacks (and reacts

quickly)

Enemy or friend? (suspects

associates and friends)

Confi ding in others is feared

Threats perceived in benign

events

Schizotypal personality disorderME PECULIAR9 Magical thinking

Experiences unusual perceptions

Paranoid ideation

Eccentric behavior or appearance

Constricted or inappropriate affect

Unusual thinking or speech

Lacks close friends

Ideas of reference

Anxiety in social situations

Rule out psychotic or pervasive

developmental disorders

Borderline personality disorderIMPULSIVE10

Impulsive

Moodiness

Paranoia or dissociation under stress

Unstable self-image

Labile intense relationships

Suicidal gestures

Inappropriate anger

Vulnerability to abandonment

Emptiness (feelings of)

Schizoid personality disorderDISTANT9

Detached or fl attened affect

Indifferent to criticism or praise

Sexual experiences of little interest

Tasks done solitarily

Absence of close friends

Neither desires nor enjoys

close relationships

Takes pleasure in few activities

Antisocial personality disorderCORRUPT9

Cannot conform to law

Obligations ignored

Reckless disregard for safety

Remorseless

Underhanded (deceitful)

Planning insuffi cient (impulsive)

Temper (irritable and aggressive)

Borderline personality disorderDESPAIRER*Disturbance of identity

Emotionally labile

Suicidal behavior

Paranoia or dissociation

Abandonment (fear of)

Impulsive

Relationships unstable

Emptiness (feelings of)

Rage (inappropriate)

* Created by Jason P. Caplan, MD

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ucators need to be aware of the mnemonics

their trainees are using and to:

• screen these tools for factual errors

(such as incomplete diagnostic criteria)

• remind trainees that although mne-

monics are useful, psychiatrists should ap-

proach patients as individuals without the

prejudice of a potentially pejorative label.

Our methodologyIn preparing this article, we gathered

numerous mnemonics (some published

and some novel) designed to capture the

learner’s attention and impart informa-

tion pertinent to psychiatric diagnosis and

treatment. Whenever possible, we credited

each mnemonic to its creator, but—given

the diffi culty in confi rming authorship of

(what in many cases has become) oral his-

tory—we’ve listed some mnemonics with-

out citation.

Our list is far from complete because we

likely are unaware of many mnemonics,

and we have excluded some that seemed

obscure, unwieldy, or redundant. We have

not excluded mnemonics that some may

view as pejorative but merely report their

existence. Including them does not mean

that we endorse them.

This article lists 32 mnemonics related

to psychiatric diagnosis. Thus, it seems

odd that an informal survey of >60 resi-

dents at the Massachusetts General Hos-

pital (MGH)/McLean Residency Training

Program in Psychiatry revealed that most

were aware of only 2 or 3 psychiatric mne-

monics, typically:

• SIG: E CAPS (a tool to recall the criteria

for depression)

Histrionic personality disorderPRAISE ME9

Provocative or seductive behavior

Relationships considered more

intimate than they are

Attention (need to be the center of)

Infl uenced easily

Style of speech (impressionistic,

lacking detail)

Emotions (rapidly shifting, shallow)

Make up (physical appearance

used to draw attention to self)

Emotions exaggerated

Narcissistic personality disorderGRANDIOSE11

Grandiose

Requires attention

Arrogant

Need to be special

Dreams of success and power

Interpersonally exploitative

Others (unable to recognize

feelings/needs of)

Sense of entitlement

Envious

Dependent personality disorderRELIANCE9

Reassurance required

Expressing disagreement diffi cult

Life responsibilities assumed by others

Initiating projects diffi cult

Alone (feels helpless and

uncomfortable when alone)

Nurturance (goes to excessive

lengths to obtain)

Companionship sought urgently

when a relationship ends

Exaggerated fears of being left

to care for self

Histrionic personality disorderACTRESSS*Appearance focused

Center of attention

Theatrical

Relationships (believed to be

more intimate than they are)

Easily infl uenced

Seductive behavior

Shallow emotions

Speech (impressionistic and vague)


Avoidant personality disorderCRINGES9

Criticism or rejection preoccupies

thoughts in social situations

Restraint in relationships due to

fear of shame

Inhibited in new relationships

Needs to be sure of being liked

before engaging socially

Gets around occupational activities

with need for interpersonal contact

Embarrassment prevents new

activity or taking risks

Self viewed as unappealing or inferior

Obsessive-compulsive personality disorderSCRIMPER*Stubborn

Cannot discard worthless objects

Rule obsessed

Infl exible

Miserly

Perfectionistic

Excludes leisure due to devotion

to work

Reluctant to delegate to others


continued

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Mnemonics

BOX 6. MNEMONICS FOR DIAGNOSING DELIRIUM

BOX 5. MNEMONICS FOR DIAGNOSING ADDICTION DISORDERS

• DIG FAST (a list of criteria for diagnos-

ing mania)

• WWHHHHIMPS (a tool for recalling

life-threatening causes of delirium).

Although this unscientifi c survey may

be biased because faculty or trainees at

MGH created the above 3 mnemonics,

it nonetheless begs the question of what

qualities make a mnemonic memorable.

Learning theory provides several clues.

George Miller’s classic 1956 paper, “The

magical number seven, plus or minus two:

some limits on our capacity for processing

information,” discussed the fi nding that 7

seems to be the upper limit of individual

pieces of data that can be easily remem-

bered.31 Research also has shown that re-

cruiting the limbic system (potentially

through the use of humor) aids in the recall

of otherwise dry, cortical information.32,33

Intuitively, it would seem that nonre-

peating letters would facilitate the recall of

the linked data, allowing each letter to pro-

vide a distinct cue, without any clouding

by redundancy. Of the 3 most popular psy-

chiatric mnemonics, however, only DIG

FAST fi ts the learning theory. It contains 7

letters, repeats no letters, and has the lim-

bic cue of allowing the learner to imagine a

person with mania digging furiously.

SIG: E CAPS falls within the range of

7 plus or minus 2, includes a limbic cue

CausesI WATCH DEATHInfection

Withdrawal

Acute metabolic

Trauma

CNS pathology

Hypoxia

Defi ciencies

Endocrinopathies

Acute vascular

Toxins or drugs

Heavy metals

Life-threatening causesWWHHHHIMPS*Wernicke’s encephalopathy

Withdrawal

Hypertensive crisis

Hypoperfusion/hypoxia of the brain

Hypoglycemia

Hyper/hypothermia

Intracranial process/infection

Metabolic/meningitis

Poisons

Status epilepticus

* Created by Gary W. Small, MD

Deliriogenic medicationsACUTE CHANGE IN MS14

Antibiotics

Cardiac drugs

Urinary incontinence drugs

Theophylline

Ethanol

Corticosteroids

H2 blockers

Antiparkinsonian drugs

Narcotics

Geriatric psychiatric drugs

ENT drugs

Insomnia drugs

NSAIDs

Muscle relaxants

Seizure medicines

Substance dependenceADDICTeD12

Activities are given up or reduced

Dependence, physical: tolerance

Dependence, physical: withdrawal

Intrapersonal (Internal)

consequences, physical or

psychological

Can’t cut down or control use

Time-consuming

Duration or amount of use is greater

than intended

Substance abuseWILD12

Work, school, or home role

obligation failures

Interpersonal or social consequences

Legal problems

Dangerous use

Alcohol abuseCAGE13

Have you ever felt you should

CUT DOWN your drinking?

Have people ANNOYED you

by criticizing your drinking?

Have you ever felt bad or

GUILTY about your drinking?

Have you ever had a drink fi rst

thing in the morning to steady

your nerves or get rid of a

hangover (EYE-OPENER)?

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(although often forgotten, it refers to the

prescription of energy capsules for depres-

sion), but repeats the letter S.

WWHHHHIMPS, with 10 letters, ex-

ceeds the recommended range, repeats the

W (appearing twice) and the H (appearing

4 times), and provides no clear limbic cue.

It may be that recruiting the limbic sys-

tem provides the greatest likelihood of

recall. Recruiting this system may add in-

creased valence to a particular mnemonic

for a specifi c individual, but this same

limbic valence may limit its usefulness in

a professional context.

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Related Resources• Free searchable database of medical mnemonics. www.medicalmnemonics.com.

• Robinson DJ. Mnemonics and more for psychiatry. Port Huron, MI: Rapid Psychler Press, 2001.

Recollecting diagnostic criteria is useful in clinical practice, on board examinations, and for insurance reimbursement. Mnemonics are well-suited to learning and recalling lists of signs and symptoms required for accurate psychiatric diagnosis.

Bottom Line

Clinical Point

We included some We included some mnemonics that mnemonics that may be viewed as may be viewed as pejorative, but that pejorative, but that does not mean does not mean we endorse themwe endorse them

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Mnemonics in a Nutshell